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DA--L~€& F?~¢-t-tLx'f'l Place of Confmement CASE NO.-'--t_0_1_;_'1_~-~--- (Clerk will assign the number) v. APPLICATION TO PROCEED IN .FORMA PAUPERIS Defendant's name and address I, t5n.Au Lro ~Do~D deClare, depose, and say I am the Plaintiff in the above entitled case. In support of my motion to proceed without being required to prepay fees, costs, or give security therefor, I state because of my poverty, I am unable to pay in advance the filing fee for said proceedings or to give security for the filing fee. I believe I am entitled to relief. I, further declare the responses which I have made to the questions and instructions below are true. 1. . Have you reCeived, within the last 12 months, any money from any of the following sources? a. Business, profession or from self-employment? Yes 0 No~ b. Rent payments, interest or dividends? Yes 0 No L1 c. Pensions, armuities or life insurance payments? Yes 0 No JZ( d. Gifts or inheritances? Yes 0 No~ e. Family or friends? Yes 0 No~ .. f. Any other sources? Yes 0 No~ If you answered YES to any of the questions above, describe each source of money and state the amount received from each during the past 12 months. · 2. Do you own cash, or do you have money in a checking or savings account, including any funds in prison accounts? Yes 0 No~ If you aD.swered YES to any of the questions above, state the total value of the items owned. 1 )~ATCIFP (REV. 9/(Jl) , .. 3. Do you own real estate, stocks, bonds, note; automobiles, or other valuable property, excluding ordinary household furnishings and clothing? Yes 0 Noef' If you answered YES, describe the property and state its approximate value. I understand a false statement in answer to any question in this affidavit will subject me to penalties for · perjury. I declare (certify, verify, or state) under penalty of perjury that the foregoing is true and correct (28 u.s.c. §1746). Signed this the __«;_~_· __day of !\-1&--:} . '20_15. Signature of Plaintiff ID Number YOU MUST ATTACH A CURRENT SIX (6) MONTH IDSTORY OF YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE APPROPRIATE INMATE ACCOUNT CERTIFICATE FROM THE LAW LIBRARY AT YOUR PRISON UNIT. 2 ~ATCIFP (REV. 9/02) TEXAS DEPARTMENT OF CRIMINAL JUSTICE RECORDS RELEASE AUTHORIZATION I, the below named and numbered offender, hereby authorize the Texas Department of Criminal Justice to · release· records· pertaining ·· to·" my ··trust fund account, as requested by Gu.r t oi ((!IIVl;~ / &ppec.{ Js (Identify Court, Attorney, or entity as defined in Rule 3 9 2 !-Special Correspondence Rules) I, offender t)~o.u Ii 0 Jose AJo rVl 0 ' - TDCJ# ·13/ 8t/l l being presently incarcerated at the Da./ ~J'e:!j ~LA '{)·b!!J County, Texas declare under penalty of peijury that the foregoing is true and correct Executed on this the 1 ., I Ei day of AIQlf'; l 20K -------L---------- ~ By. Q!wltlr A. (Offender Signature) Witness -Cnrlu. iJ . lJlfYY\fY)\&Y (Approved-Witnessing Authority Signature) INSTRUCTIONS: 1 The offe:nder completes above information, signs and dates the Records Release Authorization in the presence of the approved witnessing authority (Access to CourtS Representative) 2 The witnessing authority identifies the offender by ID card or records lmd, upon verification, witnesses the offender's signature by signing the Records Release Authorization, which the witnessing authority will maintain 3 The witnessing authority prints out a copy of the offender's ''TFBA" computer screen, certifies it, and retains a duplicate copy for their records 4 The offender is required to have an addressed, stamped envelope :prepared for mailfug 'The witnessing 'authority then places a copy of the c·~rtified "TFBA" printout in the addressed and stamped envelope and the envelope is sealed and placed in the outgoing mail . ·, .;. • • •• . :.;;; ~- ~ f '.t ATC01- Authorization No.1 (10/01) CSINIB02/CINIB02 TEXAS DEPARTMENT OF CRIMINAL JUSTICE 05/ll/l::'i DH31/SD00116 IN-FORMA-PAUPERIS DATA JDCJ#': IZ11378697 SID#: 07508892 LOCATION: DALHAfH INDIGENT DTE: 02/15/12 NAME: ADORNO,BRAULIO JOSE BEGINNING PERIOD: PREVIOUS TDCJ NUMBERS: CURRENT BAL: 0.00 TOT HOLD AMT: 0.00 3MTH TOT DEP: f.MTH DEP: 6MTH AUG BAL: 5MTH AVG DEP: MONTH HIGHEST BALANCE TOTAL DEPOSITS MONTH HIGHEST BALANCE TOTAL DEPOSITS PROCESS DATE HOLD AMOUNT HOLD DESCRIPTION NO BANKING ACTIVITY WITHIN THE PAST 6 MONTH PER I [JD. STATE OF TEXAS COUNTY OF t!o.d~. ON THIS THE _ll DAY OF _1Y:Y1::~\____ ,,~ _ , I CERTIFY THAT THIS DOCUMENT IS A TRUE, COMPLETE,AND UNALTERED COPY-lADE BY ME OF INFORMATION CONTAINED IN THE COMPUTER DATABASE REGARDING THE OFFENDER'S ACCOUNT. NP SIG: PF1-HELP PF3-END ENTER NEXT TDCJ NUMBER: OR SID NUMBER: -0~~.~ 5)\\ /~Dl5